Hyaluronic Acid Filler Pen Consent Form

Thank you for your interest in the Hyaluronic Pen Treatment. This form is intended to provide you the information you need in order to make informed decisions about the treatment. Please read through below and fill out the information required to express your intention in undergoing the treatment.

INTRODUCTION

Hyaluronic Acid treatments involve infusion purified Hyaluronic Acid into the skin. This fills the wrinkles and restores volume. Hyaluronic acid is naturally produced by your body that keeps your skin well lubricated and moist. We lose this as we age. This treatment is intended to retain Hyaluronic acid in our skin. But, just like natural Hyaluronic Acid, the injectables eventually lose their form and wears down in due time. The injectable Hyaluronic Acid can last around 6 months or longer. But since this is not permanent, a periodic treatment may be required for body retention.

PATIENTS THAT MAY NOT BE ELIGIBLE FOR THE TREATMENT

Due to certain health conditions, some may not be allowed or may be evaluated further to take this treatment. This is for the protection of the health and safety of the patient. We have enumerated here the following conditions that may prevent the patient to undergo the Hyaluronic Acid treatment and thus the injector must be notified:

1. Those who had allergic reactions to hyaluronic products
2.Those who are anaphylactic or having a history of a serious allergic reaction
3.Those who are Keloid formers
4.Those who are pregnant or nursing a child
5.Those who recently had dental/facial surgery.
6.Those who have viral infections such as herpes or simplex (cold sores)
7.Those who are under medication

I,

hereby consent to and authorize to use a needleless pen to infuse hyaluronic acid filler into my lips/skin Please read and initial each of the statements below:

I certify I am over the age of 18.

I have voluntarily elected to undergo this treatment/procedure after the nature and purpose of this treatment has been explained to me.

I understand and acknowledge that there are risks involved with the treatment I will be receiving. Although it is impossible to list every potential risk and complication, I have been informed of possible benefits, risks, and complications, and I have had the opportunity to ask questions regarding these risks and other possible complications.

I also recognize there are no guaranteed results and that independent results are dependent upon age, skin condition, and lifestyle and that there is a possibility I may require further treatments of the treated areas to obtain the expected results at an additional cost.

In the event that I may have additional questions or concerns regarding my treatment of suggested home product/posttreatment care, I will consult the esthetician immediately.

I understand there are contraindications to this treatment, including but not limited to, pregnancy, breastfeeding, sensitivity to hyaluronic acid, and severe allergies.

I certify that I am not experiencing any of the above conditions.

I understand that my technician only utilizes sterilized equipment to minimize the risk of infection or contamination and that my technician has received training in appropriate sanitation and hygiene techniques prior to performing any procedures. While the risk of infection from our procedures is extremely small, the possibility of such an occurrence cannot be totally prevented. Accordingly, I understand and accept the risk and releases my technician and the spa from any and all liability related to the subject procedure, except instances involving gross negligence.

I grant permission to take and use: photographs and/or digital images of me for use in news releases, educational materials and/or social media platforms including but not limited to Instagram, Facebook, Twitter, TicTok, and Pinterest.

I have also, to the best of my knowledge, given an accurate account of my medical history, including all known allergies or prescription drugs or products I am currently ingesting or using topically.

By signing below, I agree to the following:

I have read and fully understand this agreement and all information detailed above. I understand the procedure and accept the risks. I agree I will assume the risk and full responsibility for any and all injuries, losses, side effects, or damages which might occur to me while I am undergoing this procedure. I do not hold the esthetician, whose signature appears below, responsible for any of my conditions that were present, but not disclosed at the time of this skin care procedure, which may be affected by the treatment performed today.

Printed Name

Signature

Date

Non-Invasive Gorgeous Lip Filler